The Assessment of Knowledge, Attitude, and Practice of Paracetamol and Ibuprofen Administration Among Saudi Parents in the Makkah Region

Introduction Paracetamol and ibuprofen, widely used for pediatric fever and pain, are safe when administered correctly. However, the caregiver's lack of understanding poses risks such as overdose. Addressing knowledge gaps is crucial due to reported variations in over-the-counter medication practices. "Fever phobia" underscores parental anxiety, stressing the ongoing need for research in this healthcare domain. Methodology This is a descriptive cross-sectional design targeting Saudi parents and caregivers from the Makkah region who have children aged 0-10 years. Data was collected via a self-administered validated online questionnaire in the Arabic language using a convenient sampling technique. The data was cleaned in Excel and analyzed using SPSS version 29 (IBM Inc., Armonk, New York). Results Our study included 449 parents and caregivers in the Makkah Region, of whom 337 (75.1%) were female, 179 (39.9%) were aged 18-29, and 425 (94.7%) were Saudi nationals. Knowledge assessment revealed gaps; e.g., only 86 (26.6%) identified baby weight as a dosage factor. Attitudes varied, with 152 (47.1%) associating paracetamol/ibuprofen with liver harm. Logistic regression showed no significant predictors for high-level knowledge, positive attitudes, or good practices, except for gender-influencing good practices (p=0.035, aOR=1.839). Significantly, males exhibited better practices regarding using of paracetamol. Conclusion Our study highlights knowledge gaps among parents and caregivers in the Makkah Region regarding pediatric fever management with paracetamol and ibuprofen. Attitudes varied, and gender significantly influenced good practices, with males demonstrating better adherence to the proper practice of managing children using paracetamol and ibuprofen.


Introduction
Paracetamol and ibuprofen are commonly used over-the-counter (OTC) medications for managing fever and pain in children.They are considered safe and effective when used appropriately.However, inappropriate administration, such as incorrect dosing or frequency, may lead to adverse effects, including drug toxicity or inadequate symptom control.Due to the widespread use of these medications, it is essential to assess the knowledge, attitude, and practice of paracetamol and ibuprofen administration among caregivers.This research aims to evaluate parents' and caregivers' understanding of the appropriate use of these medications for their children and identify potential gaps in knowledge and misconceptions that may contribute to inappropriate use [1].Parents play a critical role in managing their children's health and wellbeing, often making decisions about medication administration without consulting healthcare professionals.A lack of understanding about the proper use of paracetamol and ibuprofen may lead to unnecessary risks, including overdose, underdose, or adverse drug interactions.Previous studies have reported varying levels of knowledge and practice among parents regarding the administration of OTC medications, highlighting the need for ongoing research in this area [2].
The target sample size was identified by OpenEpi version 3, and 384 participants were considered the appropriate sample size [7].The overall sample size was increased to a maximum of 500 participants in case of potential data loss and to generalize the study results more efficiently.

Study tool and scoring
We used a validated self-administered questionnaire, which was obtained from a previously published study [8].The questionnaire was generated in the Arabic language, and it is included in the Appendix.It comprised 27 questions divided into four sections.Written informed consent was required before answering the questions.The caregiver's demographic information was requested in the first section.The second section evaluated the parents' knowledge of using paracetamol and ibuprofen.The third section investigated the caregiver's perspective on using paracetamol and ibuprofen.Finally, the fourth section explored how the caregivers use paracetamol and ibuprofen.Several measures were taken to ensure the confidentiality of participants' information in this study.

Statistical analysis
The data were collected using an Excel sheet (Microsoft, Redmond, Washington).Data analysis was performed using Statistical Package for Social Sciences (SPSS) version 29 (IBM Corp., Armonk, NY, USA).Frequency and percentages were used for the descriptive analysis.Participants with scores below the median were considered to have poor knowledge, whereas those with scores equal to or above the median were considered to have good knowledge of the topic.We used a logistic regression model to analyze the sociodemographic predictors of caregivers' high knowledge levels.The significance level was 0.05.All data were anonymized.

TABLE 1: Sociodemographic and other features of the caregivers
Figure 1 shows the city-wise distribution of caregivers with Mecca being the most common city followed by Jeddah.

Discussion
Paracetamol and ibuprofen, commonly used for pediatric fever and pain, are safe when appropriately administered.Furthermore, a study was done in 2021 in Saudi Arabia on a total of 656 parents, aimed to assess their knowledge, beliefs, and behavior toward fever and its management.The study used an online questionnaire, which revealed that the most common antipyretic drugs used among parents were paracetamol, followed by antibiotics and ibuprofen [9].Similarly, Chiappini et al. (2023) show a significant reduction in body temperature one hour after administration of paracetamol and the absence of fever in almost all the children included in the study [10].Moreover, Hay et al. (2008) concluded that for unwell children with a fever, start with ibuprofen; weigh the risks of exceeding paracetamol and ibuprofen doses against the benefits (2.5 hours fever reduction) [11].In 2021, another study was done in Jeddah, assessing the knowledge, attitude, and practice of paracetamol and ibuprofen administration among 493 caregivers.The results indicated that most caregivers had inadequate knowledge regarding antipyretic administration, and half of the participants were unsure about the correct dosage [8].Moreover, a study in 2015 on 1272 pediatric patients in Al-Dammam Maternal and Child Hospital shed light on the problem of accidental poisoning among children, its factors, and epidemiology.Unfortunately, the results showed that the most common presentation was medication toxicity, and paracetamol was at the top of the list of medications [12].The caregiver's lack of understanding in this literature was demonstrated in the administration method and even in attaining the degree of toxicity [8,12].
Parents, often decision-makers in their children's health, may lack understanding, leading to risks such as overdose or inadequate symptom control.Addressing gaps in caregivers' knowledge is essential, given the reported variability in OTC medication administration practices.The term "fever phobia" highlights caregivers' anxiety, emphasizing the need for ongoing research in this critical healthcare area [13].Thus, the findings from our study provide valuable insights into the behaviors and perceptions of caregivers regarding the use of these commonly administered medications.
Our study's demographic profile aligns with existing literature to a considerable extent.The predominance of females among the surveyed caregivers (75.1%) is consistent with studies highlighting the central role of mothers in childcare decisions.The prevalence of mothers seeking healthcare information is welldocumented, underscoring the need for targeted educational interventions aimed at enhancing their knowledge and practices concerning medications for children.However, a previous study by Keizer et al. (2020) showed that both fathers and mothers equally share childcare responsibilities for children's cognitive and body development [14].Moreover, Roeters et al. (2016) showed that mothers find caring for a minor child to be meaningful while caring for an adolescent to be stressful.Fathers stress over infant care but find middle childhood care meaningful [15].Notably, the distribution of age groups in our study echoes the trend observed in similar research, emphasizing the relevance of assessing the younger age cohort (18-that should be considered when designing educational materials and interventions. Significantly, our study's knowledge assessment revealed gaps in caregivers' understanding, consistent with prior research, which shows that a low level of knowledge increases the risk of improper drug intake [8].The identification of baby weight as a factor influencing dosage selection by only 26.6% of caregivers is a concerning finding.Similarly, Pan et al. (2016) show that the weight effect may be minimal, or the proper dosage can only be determined when weight is combined with other factors [16].This aligns with studies emphasizing the importance of tailoring educational efforts to address specific knowledge deficits, such as accurate dosage calculations based on weight.
The low awareness (0.9%) of the maximum daily frequency of paracetamol administration (five times) is a critical point, highlighting the need for clearer communication on dosage limits.A previous study by Ramanayake et al. (2012) shows that eighty percent followed the correct (four times per day) dosing frequency [17].Similarly, the knowledge gaps related to ibuprofen, including recommended dose and frequency, suggest a need for focused educational campaigns targeting these specific aspects.
Caregivers' attitudes and practices provide valuable insights into their decision-making processes.The high percentage (81.7%)opposing the simultaneous administration of paracetamol and ibuprofen without consulting a doctor reflects a positive aspect of caregivers' caution.Parri et al. (2023) show that the fixeddose combination enhances efficacy and safety, ensuring better control of paracetamol and ibuprofen doses and minimizing incorrect dosage risks [18].This aligns with existing recommendations and reflects the potential impact of health education campaigns emphasizing responsible medication use.
Remarkably, the predominant reliance on healthcare professionals, especially doctors, for dosage information (75.5%) underscores the pivotal role healthcare providers play in shaping caregivers' practices.
Moreover, previous research shows that caregivers' main source of information on fever and paracetamol is their general practitioner [19].However, the relatively lower percentage seeking information from pharmacists, social media, or family members suggests avenues for expanding educational outreach through multiple channels, which can increase caregivers' knowledge and lead to safer medication practices [20].
Interestingly, 92.0% of caregivers measure their child's temperature before administering a fever reducer which is reassuring and indicates a generally responsible approach.Similarly, AlAteeq et al. (2018) show that most of the caregivers (82%) touch their children to confirm fever before administration [21].Nonetheless, the 8.0% who do not adhere to this practice highlight the importance of emphasizing temperature monitoring as a fundamental step in determining the need for antipyretic treatment.
Moreover, the logistic regression models explore potential predictors of high-level knowledge, positive attitudes, and good practices among caregivers.While demographic factors like age, gender, nationality, education, and employment did not consistently emerge as significant predictors, gender showed significance in predicting good practices.Males were more likely to exhibit good practices, indicating a gender-based variation that warrants further investigation.Similarly, in a previous study, 52.4% of fathers showed good practice as compared to 40.6% of mothers regarding fever management in children [22].Moreover, cultural factors such as beliefs and traditions play a crucial role in healthcare decision-making, and understanding these dynamics can inform culturally sensitive health education initiatives [23].

Limitations
Limitations of our study include a potential response bias due to self-reporting, limited generalizability to diverse populations, and the reliance on cross-sectional data, which restricts the establishment of causal relationships.Moreover, our research was carried out in the Makkah region with a small sample size.So, we encourage more research among Saudi citizens with a larger sample size.
In addition, questions regarding socioeconomic status, caregivers' occupation, additional information about who administers the medication, and whether caregivers have experienced health education can reveal crucial data.

Conclusions
Our study contributes valuable insights into the knowledge, attitude, and practices of Saudi parents and caregivers regarding paracetamol and ibuprofen administration.While aligning with existing literature, our findings emphasize the need for targeted interventions addressing specific knowledge gaps and cultural considerations.Tailoring educational initiatives that provide clear and concise information about the appropriate use of these medications, as well as guidelines for the safe administration and potential side effects, to the unique needs of caregivers, particularly those in the younger age group, can enhance the safe and effective use of these common medications for children.Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work.Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work.Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Table 3
shows a comprehensive assessment of the attitude and practice of caregivers regarding the use of paracetamol and ibuprofen.In terms of caregivers' attitudes, a significant portion is aware of the side effects, with 152 (47.1%) associating paracetamol and ibuprofen with liver harm and 148 (45.8%) with kidney harm.The majority seek dosage information from doctors 244 (75.5%) and pharmacists 176 (54.4%).When it comes to the form of administration, 245 (75.9%) prefer the liquid form.Notably, 264 (81.7%) believe it is incorrect to administer both medications simultaneously without consulting a doctor.In terms of caregiver practice, 236 (73.1%) measure a child's temperature using a thermometer, and 212 (65.6%) commonly use paracetamol as an antipyretic.Additionally, 297 (92.0%) measure a child's temperature before administering a fever reducer, while 252 (78.0%) make a point to read the attached leaflet.

Table 4
shows the results of a logistic regression model assessing predictors of high-level knowledge among caregivers regarding the use of paracetamol and ibuprofen.Age (p=0.924,aOR=1.010,95% CI: 0.820-1.